纵隔肿瘤ICD-10编码分析

目的 分析某三甲肿瘤专科医院纵隔肿瘤错误编码的案例,提高临床医师首页填写质量的意识,规范医师填写首页的行为,提高纵隔肿瘤ICD疾病编码的准确性。方法 调取某三甲肿瘤专科医院2021年1—7月出院病案,按照ICD-9手术编码相关原则进行检索,并对其病历首页出院诊断及病理诊断依据疾病和有关健康问题的国际统计分类ICD-10进行质控和分析。用Excel表格进行错误类型的统计工作。结果 质控病案首页88份,存在的错误类型包括形态学编码漏填或错误和疾病诊断编码错误。其中,形态学编码漏填或错误35份,占39.77%,其中以形态学编码错误为主;疾病诊断编码错误47份,占53.41%,其中纵隔肿瘤的部位编码混淆居多。结论 临床医师在首页诊断填写存在概念混淆,编码员存在临床知识缺乏,对国际疾病分类ICD-10编码知识理解不够深入,临床医师与编码员缺乏沟通。通过深入推进临床医师ICD-10疾病编码培训,设立科室专职编码质检人员,邀请临床医师讲授专业知识,促进全院病案首页填写质量的提高。     

影响手术操作编码准确性的因素及处理策略

探讨临床医师书写手术操作名称与手术编码的关系,临床医师应学习手术操作名称的正确书写。编码员素质与手术操作编码直接相关,编码员应该提高专业素养,提高工作责任心,以认真科学的态度对待编码工作,提高编码的准确率,为临床医疗、科研、教学等提供可靠信息资料。     

关于胎儿宫内窘迫的编码分类

目的 通过对胎儿宫内窘迫100份病案分析,探讨医师诊断的合格率,疾病分类编码员的编码正确性. 方法 应用计算机检索,收集2005-2006年内住院的100份胎儿宫内窘迫产妇病案进行分析. 结果 影响胎儿宫内窘迫诊断和疾病编码正确性因素,主要包括:诊断依据、编码员的业务知识和专业专科业务的了解程度. 结论 需要加强疾病分类编码员的医学知识和ICD-10的系统培训,提高医师专科业务水平.     

浅析ICD-10疑难编码

目的探讨疑难编码的原因,提高ICD编码准确性。方法对8例ICD疑难编码的原因进行分析,应用ICD-10编码规则进行疾病分类。结果造成疑难编码的原因是:一方面临床医师书写诊断不规范,另一方面编码员医学知识欠缺。结论认真细致阅读病历、分析原因,了解疾病病因、病理、临床特征,并与临床医师勾通,掌握ICD-10操作分类基本原则,学习必要的临床医学知识和外语知识,方能准确编码。     

120份肺炎的编码质量分析

目的 分析某院120份首页主要诊断为肺炎的疾病编码情况,总结分析编码错误原因,从而提高肺炎编码质量,为国家三级公立医院绩效考核肺炎单病种管理准确监测数据奠定基础,更好顺应医保按病种分值付费方式(DIP)。方法 使用某院病案管理系统检索2021年1月1日—2022年8月31日主要诊断编码类目为肺炎J12-J18的病案共2257份,随机抽取其中120份,重新审核每份病案肺炎编码情况。结果 复核120份病案中,编码错误合计18份,编码错误率为15%。其中医师填写不规范,编码员随错13份;医师填写不规范,编码员修正后仍错误2份;医师填写正确,编码员编错3份。结论 肺炎的临床诊断书写习惯与ICD-10分类轴心不同,错误率高,通过加强临床医师ICD-10编码培训,规范临床医师使用诊断名称,加强编码员临床知识及专业知识的培训,建立三级编码质控模式,进而提高肺炎编码正确率。     

建立有效学习机制 提升病案编码水平

目的提升病案编码员对疾病和手术的理性与感性认识,提高病案编码水平。方法通过建立有效学习机制,特别是后期参加临床科室的业务学习,观看编码中遇到的概念模糊和抽象的手术。结果编码员对疾病及手术有了较为透彻的理解并融会贯通,病案编码的准确性及处理疑难编码的能力大幅提高。结论建立有效学习机制,特别是参加临床科室的业务学习,能明显提高病案编码员的编码水平。     

既往史与国际疾病分类质量的关系分析

本文依据ICD-10编码原则,通过4个未看既往史造成错误编码的案例,分析说明既往史与国际疾病分类编码的关系,指导编码员准确编码,提高疾病分类质量。临床医师既往史描述是否全面、准确及编码员是否详细阅读既往史都将直接影响编码的准确性,编码员编码时一定要阅读既往史,才能科学准确编码。     

先天性畸形、变形和染色体异常疾病编码疑难解析

目的为提高先天性畸形、变形和染色体异常的疾病编码正确率及疾病的分类水平。方法以黑斑息肉病、茎突综合征、心肌桥为例,进行编码及分类过程的阐述。结果在先天性畸形、变形和染色体异常疾病的编码分类过程中,当疾病的名称和编码表中的病名不一致或不完全一致时,必须查阅病历,了解临床诊断的依据,同时,与临床知识及经验丰富的临床医生沟通,才能正确编码分类,否则,很难编码或编码错误,从而影响病案资料的查询和统计信息的真实性。结论要正确编码分类先天性畸形、变形和染色体异常的疾病,编码员必须有高度责任心,熟悉ICD的技术及疾病编码原则,编码前必须查阅相关病历资料,与主管临床医师充分交流。     

经导管射频消融术编码质量缺陷原因分析及对策

目的提高病案信息管理中编码的准确度。方法对宁夏人民医院152例经导管射频消融术编码按2种不同检索方式进行数据统计，并分析数据差异。结果手术分类编码中存在错编、漏编现象，编码未检出率达19．74％。结论拓宽编码员医学知识和分类知识的广度与深度，增强其工作的责任心，规范临床医师疾病或手术诊断名称书写，以提高疾病分类的准确性。     

常见妇产科疾病诊断与ICD-10编码

探讨如何正确选择常见的妇产科疾病诊断的国际疾病分类(ICD-10)编码,提高编码准确率。本文以妇产科疾病诊断为例,阐述某些妇产科疾病诊断名称相同、病因相同(或不同)、发病部位、发病时期、临床症状不同,编码有别。编码员要加强学习,掌握ICD-10编码原则,不断丰富自己的妇产科临床医学知识,临床医师要配合,规范书写妇产科诊断,才能保证ICD-10编码的正确,以确保医院卫生统计报表数据准确性,更好地为医、教、研服务。     

医疗服务操作分类与编码的设计与应用简

医疗服务操作分类与编码是医学信息标准化的重要组成部分,是临床数据提取、分析和应用的基础。世界卫生组织及世界多国一直致力于开发、更新和维护此分类与编码。我国此前一直沿袭美国准备在2014年停止使用的ICD-9-CM-3（卷3）,中国需要结合国际主流设计思路,根据国情开发出适宜的多轴、一体化的医疗服务操作分类与编码体系。     

基于DRGs理论谈规范应用疾病编码的必要性

目的说明规范国际疾病编码标准性是实现DRGs的重要前提。方法任意抽取了185份出院病历作为研究对象,分别使用本土化的ICD-10国际编码(广东省疾病编码库)和《疾病分类与代码(GB/T 14396-2012版)》,以下简称"国标库")及ICD-9-CM手术操作编码诊断和操作编码的一致程度作统计对比。结果主要诊断和主要手术操作的编码不一致性均大于50%。结论规范ICD-10国际疾病编码和ICD-9-CM手术操作编码标准对于实现DRGs合理分组具有重大意义。     

以人名命名疾病的ICD-10编码方法探讨——以眼科为例

眼科中很多疾病是以人名命名的疾病,这些疾病一般是以首次报告该疾病的国外眼科学家名字命名,临床医师往往直接使用人名的英文名称作为这些疾病的诊断,如Coats病、Fuchs综合征、Leber遗传性视神经病变、Duane综合征等。为查询这些疾病的正确编码,本文分别探讨这几种眼科疾病的编码查找方法,查到它们的编码分别是H35.0、H20.8、H47.2和H50.8。总结出以人名命名的疾病编码的主导词选择方法一般有2种:人名和临床表现。选择人名作主导词需要在文献资料中查询这些国外眼科学家的权威汉语音译名称,使用权威汉语音译名称作为主导词查找编码;选择临床表现作主导词需要在医学文献中充分了解这些疾病的病因、发展、诊疗和转归等情况,掌握这些疾病的临床表现。     

Health promotion in general practice: On meanings and aims in interaction

The enterprise of health promotion in medicine involves a responsibilityof distinguishing between the concepts of health and absenceof disease and of reflecting on the notions of illness and sickness.In this paper the importance of human dialogue is stressed bothas a means and end of the doctor-patient relationship and asthe main means of genuine health promotion. The outcome of healthwork is proposed to depend mainly on the way the patients areencountered. Their efforts to make themselves seen as beingsick should not on all occasions be diagnosed and treated. Bymeans of a reflected, dialogic practice patients may be listenedto and inspired to reconstruct their symbol-based relationshipto the world of meaning. The conception of health primarilyincludes man's relationship to himself. Illness is looked uponas the subject's experience of illhealth, whereas disease isunderstood as a functional imbalance of bodily organs. Thereis a tacit meaning in being ill (and found sick) that can berealized and attended to best in close relationship with thepatient. Physicians – preferably general practitioners– involved in health promotion should, it is concluded,both assist the patients to give up their sick role and continuallyelaborate their own professional competence to see and successfullyencounter the manifold specifically human issues underlyingtheir patients' presented symptoms.     

ICD-10北京临床版应用前后编码使用频度对比分析

目的 从编码使用频度角度考察国际疾病分类第十次修订本(ICD-10)北京临床版的应用状况,以利于拓展应用和发展.方法 对ICD-10北京临床版应用前(2006年)、推广中(2007年)和应用中(2008年)编码使用频度差异情况进行统计、计算相似度并做比较分析.结果 得到2006年～2008年3年北京临床版类目、亚目和后两年诊断编码的使用频次表,得出其对WHO ICD-10标准编码的使用率及2007年与2006年和2008年编码相似度,用以考察ICD-10北京临床版对WHO ICD-10的兼容性;得到2007年与2008年ICD-10北京临床版编码与WHO ICD-10亚目编码的数量关系,用以考察编码的细化效果.结论 ICI-10北京临床版与WHO ICD-10在可用编码层面具有很好的兼容性;其编码细化均衡有效;ICD-10的应用宜先本地化.     

Disease coding errors by health care organizations: effects of a government quality intervention

Disease coding errors in claims data can cause serious problems for financing, reimbursement systems, public health surveillance and health research. This study analysed a government intervention to improve coding accuracy of health care organizations in South Korea. The intervention was implemented in 1997 by 226 organizations that had submitted erroneous claims in 1996 for five selected diseases. In 1998, 94% of these organizations eliminated coding errors for these diseases. Those organizations least responsive to the intervention were tertiary hospitals, those publicly owned, and those with other complex organizational characteristics. Overall, this simple intervention appeared extremely effective, and wider adoption of such techniques should be explored.     

浅谈当代外科实习带教老师应具备的专业素质

探讨当代外科实习带教老师应该具备的专业素质,提高带教质量。在当今外科技术领域不断发展前提下,笔者结合自身多年的临床教学经验,论述新形势下外科实习带教老师应该具备以下素质：树立微创外科观念、不断更新专业知识、注重学习方法的讲授、提高外语沟通能力等多个方面。带教老师需要不断提高自身专业素质,才能培养出适合新形势发展需要的综合型医学专业人才,使之成为合格的临床医生。     

Predictors for work incapacity continuing after disc surgery.

OBJECTIVES: This study was carried out to provide information on and identify factors about the fitness for work 12 months after disc herniation surgery. In addition a predictive tool for this outcome was developed. METHODS: A selected patient population (N = 177) operated on for lumbar disc herniation from September 1995 until May 1996 was evaluated by medical advisers of a sickness fund. The patients were submitted to a standardized interview about their personal, social, medical, professional, and psychological status. To assess the functional status of the lumbar spine, a standardized clinical examination was used. RESULTS: Eighty-five percent of the patients were employed 1 year after surgery. The most important predictors at 6 weeks after intervention were the estimation of pain according to a visual analogue scale, the patient's prediction of his possibilities to resume work, the Oswestry disability index score, and the Zung depression score. Of the clinical factors, nonorganic signs and sensory disturbances after surgery were negative prognosticators for long-lasting disability. Using the Oswestry score, the Zung score, the patient's own prediction, the score on the Social Readjustment Rating Scale, and the score on the Modified Somatic Perception Questionnaire, 86% of the poor outcomes could be correctly classified. CONCLUSIONS: The Oswestry disability scale and the Zung depression scale should be included in the routine postoperative assessment after disc surgery and the patient's own prediction of his possibility for fitness for work should be taken seriously. If a poor outcome is predicted, the patient is in need of rehabilitation and should be guided more intensely.     

Planning for continuing education: goal setting and self-assessment

The American Dietetic Association placed the responsibility for professional growth and development on individual dietitians when the membership voluntarily accepted registration in 1969. One goal of registration was to improve individual competency of dietitians through their participation in continuing education activities. Such participation, to be effective, requires self-assessment of needs, formulation of goals, and the setting of priorities for learning. A recent study revealed, however, that only 20% of registered dietitians desire to assess their own learning needs and to plan their own continuing education experiences to meet those needs. This discrepancy between the goals of the professional association and the behavior of individual members may be a result of members not knowing about ways to plan effectively for their own professional growth. The "Well-Dones" method is presented as a tool for dietitians to use in planning their own learning by determining needs, setting goals, and assessing achievements. Professional concern over the improvement of competency through continuing education should be a matter of importance for each registered dietitian.     

桂林市法定传染病疫情报告管理现状调查

目的及时掌握桂林市各医疗保健机构法定传染病疫情报告管理的真实状况,为疾病预防和控制提供科学依据. 方法在各级卫生行政部门组织开展自查基础上,市级卫生行政部门依据卫生部制定的检查方案对其进行抽查及调研. 结果疫情报告管理全市平约得分32.8分(总分40分);法定传染病漏报率为9.13%,门诊高于住院部;传染病报告卡及时率为90.27%,完整率为94.33%,准确率为99.78%.结论加强和巩固三级预防保健网,重点抓住县、乡级的传染病整体管理工作中的薄弱环节,使该市传染病报告管理工作进一步规范化、制度化、法治化.